Utilization of acute inpatient psychiatric services: “Heavy users” in New York State

The severely and persistently mentally ill (SPMI) population are often forced to rely on emergency/acute inpatient services. The authors analyze Medicaid expenditures and state hospital utilization data to identify and describe the characteristics of heavy users of these services. Also described is New York State's intensive case management (ICM) initiative targeted at this heavy user group. It is postulated that ICM will alter the utilization patterns of participants from over-reliance on the most costly services and more effectively and efficiently serve the SPMI population, specifically the heavy user subpopulation.     

Team Leadership: Network Differences in Women's and Men's Instrumental and Expressive Relations

Recent studies have emphasised differences in leadership styles between women and men. Women have an interactive leadership style while men are more directive and authoritative. Social network analysis is used to examine differences in eight mental health case management teams, half formally supervised by women and half by men. The techniques used are graphical displays and measures of centrality. Results show male leaders as the most central team member for both instrumental and expressive relations. Female leaders, however, do not adhere to a single leadership style. Team centralisation also differs with gender composition of teams influencing leadership differences.     

Pseudosystematische Läsionen bei „atypischen” Encephalitiden

Zusammenfassung Im topischen Ausbreitungsmuster des entzündlichen Gewebssyndroms atypischer Encephalitiden der SSLE- und Panencephalitisgruppe können pseudosystematische Läsionen in Hirnstamm und Kleinhirn mit Ausgang in Systematrophien imitierende Substrate auftreten. Diese Läsionen sind einerseits durch sekundäre Entmarkungsvorgänge der ponto-cerebellaren Neurone infolge primärer Affektion der interfasciculären Oligodendroglia bedingt, die sich in deren schwerem Kerneinschlußbefall manifestiert. Die quantitative Variationsbreite des prädilektiven Hirnstammbefalls bei SSLE, die durch elektive Entmarkung der ponto-cerebellaren Neurone formale Ähnlichkeiten mit der olivo-ponto-cerebellaren Atrophie ergeben kann, wird an zwei einschlägigen Beobachtungen demonstriert. Anderseits handelt es sich bei den pseudosystematischen Läsionen um inkomplette bis subtotale Gewebsnekrosen als unmittelbare Folge lokal akzentuierter Entzündungsvorgänge ohne nachweisbare Einschlußkörpererkrankung der Oligodendroglia. Die Ätiologie des encephalitischen Syndroms und die Ursache seiner speziellen systemaffinen Prädilektionstopik sind unbekannt. Bei einer als Kleinhirn-Hirnstammsyndrom mit oculo-facialen Myoklonien verlaufenden subakuten Encephalitis fand sich eine pseudosystematische Akzentuierung des Entzündungsprozesses mit Markschädigung und Sklerose im Kleinhirn-Bindearm-Rubersystem bei geringer Endhirnbeteiligung. Bei längerem Verlauf können diese entzündlichen Sekundärschäden zu pseudosystematischen Atrophien und Sklerosen führen, die formale Ähnlichkeiten mit endogenen Systemdegenerationen aufweisen. Bei einer chronischen Panencephalitis mit knötchenförmigem Hirnstammbefall fand sich eine ponto-cerebellare Atrophie und Sklerose mit sekundärer Olivenatrophie und spinalen Strangdegenerationen, welche das Bild einer spino-olivo-ponto-cerebellaren Atrophie imitierte. Die Beziehungen dieser als subakute Encephalitis des Hirnstamms und Kleinhirns herausgestellten Sonderform atypischer Encephalitiden unbekannter Ätiologie zu den postencephalitischen Atrophien als prozeßhafte Nachkrankheiten gesicherter Virusinfektionen des ZNS sowie zu chronischen Systemerkrankungen des tierischen Nervensystems infolge langsam wirkender oder latenter Virusinfektionen werden diskutiert.

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Summary Within the topical pattern of the inflammatory process of atypical encephalitides of the SSLE and panencephalitis group pseudosystemic lesions of brain stem and cerebellum may occur which can terminate in substrates similar to system atrophies. These lesions may result from secondary demyelination of the pontocerebellar neurons caused by primary affection of the interfascicular oligodendroglia that manifests itself in a significant inclusion body disease of the oligos. The quantitative variability of the predilective affection of brain stem and pontine basis in SSLE which, by elective demyelination of the ponto-cerebellar neurons, may reveal formal similarities to olivo-ponto-cerebellar atrophy, is demonstrated in two relevant cases. On the other hand, these pseudosystemic lesions represent incomplete to subtotal necroses as direct sequelae of the locally accentuated inflammatory process without significant inclusion bodies in the oligodendroglia or neurons. The etiology of the encephalitic syndrome and the causes of its system-bound predilective pattern are unknown. In a case of subacute encephalitis clinically presenting a cerebellar-mesencephalic syndrome with oculo-facial myoclonies, there was pseudosystemic accentuation of the inflammatory process associated with demyelination and sclerosis of the cerebellum-brachium conjunctivum-ruber system and minor affection of telencephalon. In prolonged course these inflammatory sequelae may result in pseudosystemic atrophies and scleroses showing formal similarities to endogenous system degenerations of the CNS. In a case of chronic panencephalitis with nodular brain stem affection, there was a ponto-cerebellar atrophy with secondary olivary atrophy and degeneration of spinal tracts closely imitating the picture of spino-olivo-ponto-cerebellar atrophies. The relations of this special type of atypical sporadic encephalitides of unknown etiology, preliminarily denominated as subacute encephalitis of brain stem and cerebellum, to chronic postencephalitic atrophies which represent process-like sequelae of verified or suspected virus infections of the CNS and to chronic system degenerations of the nervous system in animals caused by slow and latent virus infections are discussed.

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Im Auszug vorgetragen auf der wiss. Tagung der Österr. Arbeitsgemeinschaft f. Neuropathologie in Bad Goisern, am 23. Mai 1966.     

Experimental cerebral ischemia in Mongolian gerbils

Summary Light microscopic observations were carried out on Mongolian gerbils (Meriones unguiculatus) subjected to a partial cerebral ischemia by occlusion of the left common carotid artery at the neck. About 30% of gerbils developed an ischemic injury in the ipsilateral hemisphere and their brains revealed the following histopathologic features: 1. the changes were related to the intensity (duration) of the ischemic insult and to the time elapsed following release of the occlusion. The ischemic lesions appear to progress after re-establishment of the circulation and this presents one facet of a maturation phenomenon which seems to be a general principle applicable to various parameters of ischemic injury. The rate of maturation of the lesions is related to the intensity of the ischemic insult, a lesser intensity resulting in longer development of lesions. 2. The changes were either focal or diffuse in character. The former were assumed to be directly related to a vascular involvement; among the latter the topistic distribution of the hippocampal changes suggested a feature of selective vulnerability. 3. An indirect indication of neuronal recovery was surmised from observations on animals sacrificed after different periods following occlusions of the same duration. Also capable of recovery was a reactive change observed in the H3 neurons of the hippocampus. This change was characterized by central chromatolysis and resembled the primäre Reizung of Nissl.     

Cerebral hemodynamics and “re-build-up” phenomenon on electroencephalogram in children with moyamoya disease

Re-build-up phenomenon, induced by hyperventilation, is a characteristic finding on electroencephalogram (EEG) in children with moyamoya disease, and suggests close correlation with cerebral ischemic attack. Its mechanism, however, remains obscure. In this study, we examined the relationship between the cerebral hemodynamics and this phenomenon before and after vascular reconstructive surgery. Regional cerebral blood flow and its reactivity to acetazolamide were analyzed using the xenon-133 inhalation method and single photon emission computed tomography in six children with moyamoya disease. These results were compared with the EEG. Regional vasoreactivity to acetazolamide was significantly lower in re-build-up-positive regions than in re-build-up-negative regions. Postoperative studies revealed a significant improvement of reactivity in the regions where the re-build-up phenomenon disappeared after surgery. These results suggest that the re-build-up phenomenon represents a focal reduction of the cerebral perfusion reserve in moyamoya disease.     

Psychomotor disturbances in psychiatric patients as a possible basis for new attempts at differential diagnosis and therapy

Summary This study investigates the existence and course of psychomotor symptoms in schizophrenic patients (n = 57, both treated and untreated with antipsychotic drugs) as compared to 25 healthy controls. Previous psychometric studies had suggested the existence of a psychotic motor syndrome (PMS) both in (untreated) schizophrenic and endogenous depressed patients, consisting of disturbances of lip and tongue movements, fine and gross movements of the dominant right hand and impaired complex motor coordination of the extremities. We confirmed the existence of the PMS in this study. There was no correlation of the PMS with the psychopathological status of the patients, or with extrapyramidal side-effects of the drugs used, perhaps indicating an independent basic syndrome (Basisstörung). Factorial analyses revealed similar structures both in schizophrenic and healthy persons; the differences in motor performance may be due to an impairment of the first factor general motor ability in schizophrenic patients. The PMS did not disappear parallel to the psychopathological improvement of the patients, nor in the symptom-free remission interval. The role of the PMS as possible independent biological marker syndrome for schizophrenia can consequently be further supported, with its implications towards the differential diagnostic and therapeutical values of this syndrome.Supported in part by the Deutsche Forschungsgemeinschaft (DFG Gu 207/2-1).     

The effect of oxidative stress on amyloid precursor protein processing in cells engaged in β-amyloidosis is related to apolipoprotein E genotype

The reduced antioxidative defense in allele 4 carriers is suggested to contribute to -amyloidosis in Alzheimers disease and Downs syndrome. We studied the effect of oxidative stress on accumulation of amyloid- peptide (A) in vascular smooth muscle cells (SMCs) that are engaged in production of amyloid- in vivo. Previously, we found that oxidative stress caused by ferrous ions induced accumulation of A-apolipoprotein E deposits in lysosomes and was associated with a greater oxidative protein damage in 4 carriers. Here, we demonstrate that ferrous ions induce formation of A deposits also in vascular tunica media in organotypic cultures of whole brain vessels, suggesting the role of oxidative stress in development of vascular -amyloidosis. Cellular accumulation of A in SMCs treated with ferrous ions was associated with a greater accumulation of C-terminal amyloid precursor protein (APP) fragments in 4/4 than in 3/3 myocytes and reduced the amount of soluble APP in 3/3, but not 4/4, cultures. Antioxidant vitamin E prevented these effects, and, when applied alone, diminished the amount of APP C-terminal fragments and increased the amount of secreted APP in 3/3, but not 4/4, cells. C-terminal APP-immunoreactive material was accumulated in lysosomes partly with A- and N-terminal APP immunoreactivities. These results suggest that the increased accumulation of APP and its fragments in lysosomes may yield additional amounts of cellular A, particularly in 4 carriers. We hypothesize that the altered processing of APP in SMCs locally exposed to oxidative stress facilitates cellular deposition of A and contribute to the increased risk of development of -amyloidosis in 4/4 carriers.     

The consultant as insider and change agent: The problem of boundaries in social systems

A consultant who is an insider must be sensitive to ethical and psychological issues in human systems that are of lesser import to outside consultants. Organizational boundaries are considered as being created by the norms required for membership in the system rather than from outside.Hans Falck, Ph.D., is Regenstein Professor of Social Sciences at the Menninger Foundation, Topeka, Kansas.     

Relationship of maternal parenting behaviors to preschool children's temperament

Mothers of 182 preschool nursery school children rated their own parenting responses on a Parent's Report questionnaire. At the same time the mothers responded to the Behavior Style Questionnaire (BSQ) from which scores were determined for nine categories of temperament. On the basis of category scores the children were grouped into one of five temperament clusters i.e. easy, difficult, slow to warm up, high intermediate, low intermediate. The children's membership in BSQ clusters was independent of sex, age, birth order, and mothers employment status but there was a significantly higher ratio of easy children from higher socioeconomic classes I and II. Mothers of children grouped in either the difficult or slow to warmup clusters were more likely to use guilt inducing and temper-detachment parenting styles than mothers of children grouped in the easy cluster.     

Hyperkinetic children: Early indicators of potential school failure

Hyperkinetic children are identified as a population-at risk upon admission to kindergarten. The etiology of hyperkinetic behavior is controversial. Organic driveness, hyperkinetic behavior disorder, postencephalitic behavior, brain damage with behavioral and conceptual deficit, Strauss syndrome, have all been used to label essentially similar symptom constellations. Bypassing the area of controversy, a study is reported that demonstrates that children who were identified as hyperkinetic (using behavioral criteria developed in an earlier study) were (1) absent from school more frequently, and (2) did remarkably less well on standardized tests of school readiness than their peers rated nonhyperkinetic. The implications are discussed and suggestions made for the development of intervention programs.An earlier version of this paper was presented at the Annual Meeting of the American Orthopsychiatric Association, March, 1967.     

Determinants of intellectual outcome after surgical revascularization in pediatric moyamoya disease: a multivariate analysis

Objects The aim of this study was to clarify predictors for poor intellectual outcome in pediatric moyamoya disease.Methods Fifty-two pediatric patients were included. Clinical diagnosis was transient ischemic attacks (TIA) in 35 and completed stroke in 17. Ten patients underwent indirect synangiosis through small craniotomy, whereas the other 42 underwent superficial temporal artery (STA)–middle cerebral artery (MCA) anastomosis and indirect synangiosis through large craniotomy. Full-scale IQ (FSIQ) was measured using the Wechsler intelligence scale for children (WISC) after surgery. Multivariate logistic regression models were applied to test the effect of clinical factors on intellectual outcome.Results and conclusion Eight patients revealed mentally impaired status (FSIQ<70). Multivariate analysis revealed that completed stroke and small craniotomy surgery were significantly associated with poor intellectual outcome. Odds ratios of each factor were 33.4 (95% CI, 2.4–474) and 19.6 (95% CI, 1.8–215) respectively. Early diagnosis and the revascularization procedure over as wide an area as possible may be essential to improve their intellectual outcome.     

Prevalence of known and hidden alcoholism in the revisited lundby population

Summary Using the new data from a second followup of the Lundby 1947 cohort, the aim of the present paper has been to analyze some relationships between known and hidden alcoholism in a Swedish general population sample. Information was collected by psychiatrists trough free, exploratory field interviews checked against documentary records. Alcoholism was medically defined for present purposes. Information was obtained for 98% of the 952 men surviving the cross-section date July 1, 1972. The distribution of alcoholism and other psychiatric disorders in the total population and in age subgroups was analyzed epidemiologically. The true prevalence of alcoholism in the adult men was 9.5%, comprising 7.2% known and 2.3% hidden. The proportion of hidden to known cases was 0.301 (Temperance Boards 0.871, Psychiatric Agencies 0.961, Drinking and driving offences 4.31). The main finding that about 70% of male alcoholics in Lundby appears to be known to the agencies is at variance with current views that there is an iceberg under the tip, though consistent with Rubington's suggestion that so-called hidden alcoholism is not totally but partially invisible in welfare societies.     

Apolipoprotein E co-localizes with newly formed amyloid β-protein (Aβ) deposits lacking immunoreactivity against N-terminal epitopes of Aβ in a genotype-dependent manner

Different types of amyloid -protein (A)-containing plaques occur in brains of Alzheimers disease (AD) patients. Diffuse plaques seen during early stages of AD differ from neuritic plaques in later stages both with respect to the length of the A peptides and the presence of other proteins, e.g., apolipoprotein-E (apoE). Since apoE is involved in A transport and clearance, and the 4-allele of the apolipoprotein-E gene (APOE) is a major risk factor for sporadic AD, it is plausible to speculate that apoE plays a pathophysiological role in the initiation of A deposition. To address the issue of whether binding of apoE to A is involved in initial A deposition, we studied the human medial temporal lobe of 60 autopsy cases encompassing the full spectrum of AD-related pathology. In temporal lobe regions, which become involved for the first time at a given stage of -amyloidosis, all plaques represent newly formed plaques, and these were studied with immunohistochemical methods. ApoE was present in 36 cases, and was frequently co-localized with newly formed A deposits detectable with anti-A₄₂ but not with antibodies raised against N-terminal epitopes of A. In 10 additional cases, immunoreactivity against apoE was completely lacking in newly formed plaques, which, at the same time, displayed immunoreactivity against N-terminal epitopes of A. The failure of N-terminal epitopes of A to co-localize with apoE in newly formed plaques indicates that these deposits presumably contain apoE-A complexes, in which the N-terminal epitopes of A are often concealed after complexing with apoE, thus preventing subsequent binding of antibodies. Moreover, apoE-positive newly formed plaques were seen more frequently in APOE 4/4 cases than in non-APOE 4/4 individuals, thereby underlining the potentially crucial role of apoE for the development of A deposits.     

Die Bedeutung der diskontinuierlichen Zonierung des Immunglobulinbereiches für die Diagnose neurologischer Erkrankungen

Zusammenfassung 1. 340 Patienten, welche bei der agarelektrophoretischen Auftrennung der Liquorproteine eine diskontinuierliche Zonierung im Bereiche der -Globuline zeigten, wurden bezüglich Verteilung dieser clonalen -Zonen auf die verschiedenen neurologischen Erkrankungen untersucht.2. Bei der MS und den anderen entzündlichen neurologischen Erkrankungen findet sich eine Häufung der schnell wandernden Zone ₂ und der mittelschnell wandernden Zonen ₃ und ₄.3. Bei den Discushernien und den zentralnervös-nichtentzündlichen Erkrankungen ist die Zonenverteilung ziemlich flach und undifferenziert, wobei hier wie auch bei Tumoren und Polyneuritiden der relativ hohe ₀-Anteil auffällt als ein Phänomen, das bei zentralnervös-entzündlichen Prozessen nur selten anzutreffen ist. In den wenigen Tumorfällen mit -Zonierung scheint die ₄-Position deutlich zu überwiegen.4. In der Hälfte aller MS-Liquoren mit -Zonierung ist das Totalprotein, in einem Sechstel das Total--Globulin (rel%) normal, und nur bei zwei Dritteln finden sich Plasmazellen. Die elektrophoretische Feststellung von -Zonierung ist in der neurologischen Labordiagnostik folglich ein wichtiges Hilfskriterium.5. Mit zunehmendem Anstieg des -Globulin-Gehaltes im Liquor läßt sich bei MS-Patienten, nicht aber bei allen Krankheitsgruppen, eine Zunahme der Häufigkeit der -Zonierung nachweisen.6. Das Auftreten von -Zonierung ist bei den zentralnervös-entzündlichen Krankheiten und der MS sechsmal häufiger als bei den zentralnervös-nichtentzündlichen Krankheiten.7. -Zonierung scheint beim Gesunden, bei psychiatrischen Erkrankungen, Myopathien, bei gewissen Tumoren (Neurinomen) und metabolisch bedingten Polyneuritiden nicht vorzukommen.

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The significance of discontinuous zonation of electrophoretically separated globulins for the diagnosis of neurological diseases

Summary 1. 340 patients in whom discontinuous zonation of the globulin region was observed after electrophoretic separation of the CSF proteins were examined to see how the distribution of these clonal zones is correlated with different neurological diseases.2. In multiple sclerosis (MS) and other inflammatory diseases of the CNS, zones are most frequently found in the medium positions: ₂, ₃ and ₄.3. In disk hernias and the noninflammatory diseases of the CNS, the dispersion of zone frequency is rather undifferentiated. In these conditions and in tumors of the CNS and polyneuritis, the relatively high proportion of ₀ zones is a conspicuous feature; it is scarcely encountered in inflammatory processes of the CNS. The rare cases of tumors with zonation show a preponderance of the ₄ zone.4. The total protein content is normal in half of all MS fluids with zonation; in one sixth the relative amount of total globulin is also normal, whereas plasma cells are demonstrable in only two thirds. The electrophoretic evaluation of zonation is, therefore, an important tool in neurological laboratory work.5. Increased amounts of globulin in CSF are accompanied by an increased frequency of zonation in some diseases, such as MS, but not in tumors or vascular processes.6. The incidence of zonation is about 6 times higher in MS than in noninflammatory diseases of the CNS.7. zonation seems not to be present in healthy persons, in psychiatric diseases, myopathies, some tumors (neurinoma) and polyneuritis of metabolic-toxic etiology.

     

Fluctuating parkinsonism: a pilot study of single afternoon dose of levodopa methyl ester

Thirty-four patients with idiopathic fluctuating Parkinson's disease and early afternoon delayed on or severely resistant off periods, in spite of long-term antiparkinsonian therapy, were studied. The first afternoon levodopa administration was substituted with an equimolar dosage of the liquid formulation levodopa methyl ester (LDME). The major end-points for efficacy were latency to on and duration of on periods. The patients were divided into five subgroups according to their baseline treatment and they were evaluated monthly for 6 months using the Unified Parkinson's Disease Rating Scale. The patients completed weekly self-evaluation using an on-off chart. LDME was well tolerated by all the patients. A statistically significant reduction in latency to on was observed in all patients. The clinical effect of LDME remained stable during the treatment period (repeat measures ANOVA). The more rapid clinical effect of LDME and its stable and predictable antiparkinsonian activity represents a new and useful approach for treating patients with complicated Parkinson's disease.     

Equivocal neurological signs,child development,and learned behavior

Ten children were tested repeatedly for five motor tasks commonly labeled soft signs. Finger approximation, walking heel to toe, and the equivocal Babinski improved significantly with practice. These results are interpreted as eliminating these tasks from evidence of minimal brain damage and questioning the validity of their inclusion in developmental tests.     

Clinical Evaluation of Attention-Deficit Hyperactivity Disorder by Objective Quantitative Measures

This study assessed the diagnostic potential of the actigraph, the Continuous Performance Test, and the Matching Familiar Figures Test in diagnosing attention-deficit hyperactivity disorder (ADHD). Twenty boys previously diagnosed with ADHD and 52 controls were examined. By these measures the boys with ADHD were differentiated from the controls with sensitivity and specificity above 75%. We were able to classify ADHD into eight subtypes by combining the scores of the actigraph and the CPT: hyperactive-impulsive, hyperactive-inattentive, impulsive-inattentive, hyperactive, impulsive, inattentive, mixed, and unspecified type. These classifications may be useful in diagnosing ADHD.     

Expression of transforming growth factor-β1 and interleukin-1β mRNA in rat brain following transient forebrain ischemia

Transforming growth factor-1 (TGF-1) and interleukin-1 mRNA expression were studied in rat brains after 30 min of global ischemia by in situ hybridization. Ischemia was produced by four-vessel occlusion followed by different recirculation times ranging between 15 min and 7 days. TGF-1 mRNA could first be detected 3 days after ischemia in the hippocampus, in layers II/III of cortex, in the striatum and in parts of the ventral thalamus. At 7 days after recirculation a prominent increase in TGF-1 mRNA was observed in the CA1 sector of the hippocampus. Induction of interleukin-1 mRNA, however, was less marked and limited to the rostral striatum 3 and 7 days after ischemia. TGF-1 expression 7 days after ischemia correlated well with the histological localization of regions where neuronal degeneration and subsequent astrocytic and microglial activation had occurred. In adjacent brain sections, the distribution of TGF-1 mRNA after 7 days closely resembled that of the immunostaining pattern of activated microglia, indicating that at this time point TGF-1 mRNA was mainly produced by microglial cells. The late induction of TGF-1 mRNA after ischemia points to an involvement in the persistent glial response rather than the initial glial activation. The differential pattern of interleukin-1 mRNA induction indicates regional variations of cytokine production after ischemic brain lesions.Supported in part by a grant from the European Charcot Foundation for Multiple Sclerosis Research (to J.G.)     

“On-off” phenomenon in Parkinson's disease: Correlation to the concentration of dopa in plasma

Summary To investigate the relation between on-off fluctuations in symptomatology and bioavailability of dopa in patients with Parkinson's disease, five Parkinsonian patients with pronounced on-off symptoms were studied. Continuously during the study the degree of disability in the patients was registered. Every one hour, and in addition, whenever there was a change from on to off or vice versa, a blood sample was collected for dopa determination. Since dopa is transported from plasma into the brain by a saturable carrier for which it has to compete with endogenous large neutral amino acids (LNAA), the concentrations of these competitors were measured too.In four of the patients there were considerable oscillations in the plasma dopa concentration during the day; in one of these patients the highest value was as much as 12 times higher than the lowest value. These dramatic fluctuations in the absolute concentration of dopa in plasma had a major influence on the relative dopa concentrations (calculated as the ratio dopa/sum of LNAA) as the fluctuations in the concentrations of LNAA in plasma were much less pronounced. Consequently, the absolute and the relative concentrations of dopa in plasma were highly parallelled.In four of the five patients on-periods began within one hour after a peak in the concentration of dopa in plasma and in the fifth patient five out of seven on-periods were preceded by a rise in plasma dopa concentration within the same time interval.From the present data it could be concluded that the on-off phenomenon in Parkinson's disease, at least partly, is due to oscillations in the concentration of dopa in plasma. A reduction in the variations of the concentration of dopa in plasma seems to be necessary to overcome the on-off problem. The introduction of a slow release preparation of dopa is therefore urgently warranted. The concentration of LNAA in plasma must, however, also be considered in this context.     

Apurulent bacterial meningitis (compartmental leucopenia in purulent meningitis)

Summary Meningococci and Haemophilus influenzae may invade the subarachnoid space during the bacteriaemic phase without impairment of the blood-CSF barrier and in the absence of any leucocyte reaction. In pneumococcal meningitis the CSF may also contain less than 100 cells/l despite the presence of pure bacterial cultures, but the barrier is completely broken when the serum/CSF concentration ratio is below 10. A clinical analysis of eight patients with fewer than 100 cells/l revealed that the first symptoms of meningitis appeared at least 3 days prior to the diagnostic lumbar puncture. There was a strong neutrophilic reaction in the blood with a prevalence of juvenile forms in most cases, indicating intact antibacterial defence mechanisms. Within 24 h after the start of antibiotic therapy the cell number rose above 2000/l accompanied by disappearance of pneumococci. Six of the eight patients died. In three cases autopsy revealed thick layers of pus over the convexities, indicating a compartmental separation of the ventricles and the spinal subarachnoid space. In one case of late diagnosed bacterial meningitis with a pleocytosis of 430/l the CSF lysozyme level was seven times higher than compatible with this cell number. Hyperphagocytosis and cellular disintegration is thought to cause the leucopenia within the spinal CSF compartment. Apurulent bacterial meningitis can be seen as a disease entity that is a diagnostic pitfall and also a prognostic sign.